More than 1.7 million patients per year present to the emergency department requiring treatment for chronic obstructive pulmonary disease (COPD), with about 20% requiring inpatient hospitalization. This costs the United States, directly and indirectly, between $35 and $50 billion each year.

In patients with purulent sputum, a short course of antibiotics is warranted. Community-acquired pathogens include Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis. In critically ill patients, Pseudomonas and methicillin-resistant Staphylococcus aureus (MRSA) are more common, and antibiotic regimens should be tailored to cover those pathogens as well.

COPD has huge economic and human burdens in the US. In fact, in 2010, two studies estimated that COPD exacted a direct and indirect cost of somewhere between $36 and $50 billion dollars in the US. With respect to the ED – in 2011, there were more than 1.7 million ED visits for COPD-related problems, with nearly 1/5th requiring hospitalization.

This episode of EB Medicine’s EMplify podcast is hosted by Jeff Nusbaum, MD, and Nachi Gupta, MD. This month’s corresponding full-length journal issue of Emergency Medicine Practice was authored by a strong team from the University of Maryland: Drs. Van Holden, Donald Slack, Michael McCurdy, and Nirav Shah. It was peer reviewed by Dr. Gabriel Wardi of the University of California San Diego and Dr. Geralda Xavier of Kings County Hospital in New York City.

The mMRC Dyspnea Scale is easy and efficient to use. It provides a baseline assessment of functional impairment attributable to dyspnea from respiratory disease, and correlates with healthcare-associated quality of life, morbidity, and possibly mortality for patients with respiratory diseases (particularly COPD).

The mMRC Dyspnea Scale has been used for almost two decades in multiple different heterogeneous patient populations. It correlates with other clinical and research dyspnea indices. Interrater reliability for the scale is very high.

When To Use

Use in patients with respiratory diseases like COPD, to assess degree of baseline functional disability due to dyspnea.

Next Steps

The mMRC Dyspnea Scale is best used to establish baseline functional impairment due to dyspnea attributable to respiratory disease; tracking the mMRC over time or with therapeutic interventions is of less certain clinical utility.

A patient’s mMRC Dyspnea Scale score, or another dyspnea measurement, such as the COPD Assessment Test (CAT), is combined with the patient’s FEV1 percent predicted and the frequency of COPD exacerbations to guide treatment interventions using the GOLD treatment guidelines (http://goldcopd.org).

While the mMRC is correlated with morbidity and mortality for patients with respiratory disease, currently available data do not confirm attributable cause and effect between mMRC scores and patient-centered outcomes. Measuring mMRC Dyspnea Scale scores in patients with respiratory disease (particularly COPD) to establish baseline functional dyspnea burden is appropriate, but scores are not independently used in clinical practice to guide clinical management or therapeutic interventions. However, the Global Initiative for Obstructive Lung Disease (GOLD) treatment guidelines have, since 2011, included the mMRC as a component of a multi-faceted assessment and treatment approach to patients with COPD.

The Medical Research Council (MRC) scale was developed in the 1950s based on questions used by healthcare providers in the Pneumoconiosis Research Unit in Cardiff, Wales, and was first referred to in a manuscript in 1952 (Fletcher 1952). The original MRC scale was developed from these clinical questions and used in numerous research studies over the past 60 years. The MRC was modified in a study in 1988, generating the modified Medical Research Council (mMRC) scale.

The original study of the mMRC involved 161 patients with shortness of breath at a single medical center (Mahler 1988). Of the 161 patients, a diagnosis for their dyspnea could only be determined in 153 patients, who constituted the research cohort. Patients’ mMRC scores were compared to other dyspnea measures (BDI and OCD) and spirometric results (FEV1, FVC, and maximum inspiratory and expiratory pressures). Inter-rater reliability of the mMRC was 98% in this study, and the mMRC was moderately to strongly correlated with the OCD and BDI indices. mMRC moderately correlated with pulmonary function measurements.

A subsequent validation study of 161 patients at a single outpatient clinic in Japan demonstrated factor grouping of the mMRC with other dyspnea measurements (BDI and OCD) and healthcare-related quality of life (Hajiro 1998). Furthermore, mMRC scores moderately to strongly correlated with functional assessments of patients’ cardiopulmonary fitness (including FEV1, RV/TLC, and VO2 max).

Subsequent single center and small- to moderate-sized studies have consistently demonstrated moderate correlations between the mMRC and other dyspnea scores (Chhabra 2009). mMRC scores have been shown to be highly correlated with healthcare-associated quality of life, particularly for patients with COPD (Henoch 2016). However, correlations between mMRC scores and spirometric results, ABG results, or 6-minute walk distance were not noted in some studies, such that the association between mMRC results and functional metrics is uncertain (Chhabra 2009).

The DECAF Score can be used in patients who have evidence of both pneumonia and COPD.

Better predictor of in-hospital mortality than CURB-65 in patients who have both pneumonia and an acute exacerbation of COPD.

Uses routinely available variables.

Variables from initial labs are used to calculate the score.

Requires eMRCD score, which may be difficult to obtain in patients with acute encephalopathy, dementia, or those who are intubated.

In patients with SpO2 >92% without supplemental oxygen (or otherwise for whom ABG is deemed unnecessary), 0 points should be as-signed for acidemia.

Validated for use at the time of admission in UK hospitals, but not yet validated in US EDs.

Why and When to Use, and Next Steps

Why To Use

The DECAF Score may assist clinical decision-making in terms of early discharge, escalation of care, or discussion of goals of care. Low risk (score 0-1) patients may be appropriate for early supported discharge, and high risk (score 3-6) patients may be appropriate for higher levels of care, and/or addressing goals of care.

Increasing scores may correlate with longer length of stay.

When To Use

Use in patients hospitalized with a primary diagnosis of acute exacerbation of COPD as follows:

Do not use if patient has <12 months life expectancy or is on home oxygen.

Next Steps

High risk DECAF Scores (3-6) are associated with both high risk of death and short time to death. Consider early escalation in care, higher level of monitoring versus palliative care for these patients.

Low risk DECAF Scores (0-1) are associated with low mortality risk and these patients may be candidates for early discharge.

The DECAF Score should only be used in admitted patients with a primary diagnosis of an acute COPD exacerbation, not in the outpatient setting or in patients whose COPD is stable. DECAF Scores of 5 and 6 were found to have the highest risk of death and the shortest time to death, and may warrant early evaluation for escalation of care, higher level of monitoring, or potential palliative care.

The DECAF Score was derived from evaluating variables associated with in-hospital mortality from a prospective cohort of 920 patients recruited over 2 years from 2 institutions in the UK. From this cohort five independent variables with the strongest predictive ability for in-hospital mortality were selected to create the DECAF Score.

Recruited patients were ≥35 years of age, had ≥10 pack-year smoking history, evidence of preadmission airflow limitation (FEV1/FVC <0.70), and were hospitalized with a primary diagnosis of acute exacerbation of COPD. Excluded patients were those with a comorbidity expected to limit survival to less than 12 months, and those on home oxygen.

The DECAF Score was internally validated and performed well to predict in-hospital mortality. It was later externally validated in 2 cohorts of patients. The first cohort was made up of 880 patients from the same hospitals as the original derivation study. The second cohort included 845 patients from 4 different hospitals in the UK.

In both of these validation cohorts, the DECAF Score performed well to predict in-hospital mortality and again bested other scoring systems including BAP-65, CAPS, APACHE II, and CURB-65.

Publication Date

CME Expiration Date

CME Information

Describe the differential diagnosis for patients who present with presumed acute exacerbation of COPD, considering potential comorbid or exacerbating conditions.

Apply a tailored diagnostic approach based on the severity of the exacerbation.

Treat COPD aggressively using an evidence-based algorithm.

Determine the best disposition option for patients with acute exacerbation of COPD, based on individual risks and benefits.

Physician CME Information

Date of Original Release: October 1, 2017. Date of most recent review: September 10, 2017. Termination date: October 1, 2020.

Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME.

Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ACEP Accreditation: Emergency Medicine Practice is approved by the American College of Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.

AAFP Accreditation: This Enduring Material activity, Emergency Medicine Practice, has been reviewed and is acceptable for credit by the American Academy of Family Physicians. Term of approval begins 07/01/2017. Term of approval is for one year from this date. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Approved for 4 AAFP Prescribed credits.

AOA Accreditation: Emergency Medicine Practice is eligible for up to 48 American Osteopathic Association Category 2-A or 2-B credit hours per year.

Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 1 Pharmacology CME credit, subject to your state and institutional approval.

Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.

Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.

Discussion of Investigational Information: As part of the journal, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration–approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product.

Faculty Disclosure: It is the policy of EB Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for this CME activity were asked to complete a full disclosure statement. The information received is as follows: Dr. Holden, Dr. Slack, Dr. McCurdy, Dr. Shah, Dr. Wardi, Dr. Xavier, Dr. Mishler, Dr. Toscano, and their related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation. Dr. Jagoda made the following disclosures: Consultant, Daiichi Sankyo Inc; Consultant, Pfizer Inc; Consultant, Banyan Biomarkers Inc; Consulting fees, EB Medicine.

Commercial Support: This issue of Emergency Medicine Practice did not receive any commercial support.

Earning Credit: Two Convenient Methods: (1) Go online to www.ebmedicine.net/CME and click on the title of the article. (2) Mail or fax the CME Answer And Evaluation Form (included with your June and December issues) to EB Medicine.

Hardware/Software Requirements: You will need a Macintosh or PC to access the online archived articles and CME testing.

Additional Policies: For additional policies, including our statement of conflict of interest, source of funding, statement of informed consent, and statement of human and animal rights, visit www.ebmedicine.net/policies.